Skin tags—or acrochorda—are common dermatologic conditions seen in primary care. They are typically located in the skin folds of the neck, axilla, groin, and submammary areas; and their appearance can be associated with obesity, diabetes, dyslipidemia, hypertension, or insulin resistance.1
Although there are some case reports of an acrochordon on the labium majus in the literature (ie, 1 reported a rapid growth during pregnancy while another described a rapid growth following puberty) few cases involved sizes greater than 5 mm.2-7 Conducting vulvar procedures in the family practice setting is difficult for family doctors both because of lack of familiarity with the procedures and risk of bleeding in the highly vascular vulvar region.8,9 Here we present a case of a patient with a giant vulvar acrochordon who presented to an academic family practice unit for diagnosis and who had the skin tag successfully removed using local anesthesia and surgical procedures common to family practice.
Case
A 36-year-old patient presented to her family doctor for a routine Papanicolaou test. On examination of the vulva, a single, nonpigmented, pedunculated, pear-shaped, soft, nonindurated mass arising from a broad-based stalk was noted on the right labium majus (Figure 1). There were no signs or symptoms of infection and no discharge. The patient indicated the mass had formed 12 months earlier and had steadily grown in size since then. The mass was mobile and not tethered. There was no palpable pulse in either the stalk or the mass itself. The mass did not increase in size with Valsalva maneuver. The patient had no medical conditions such as hypertension, diabetes, insulin resistance, or dyslipidemia. She was not taking any blood thinners and had no history of bleeding disorders, easy bruising, or menorrhagia. She did not have similar masses elsewhere on her body. The patient did find the mass bothersome, particularly when wearing tight clothing and during sexual intercourse.
Large vulvar skin tag prior to procedure
At the time, there was a lengthy wait (greater than 9 months) to see a gynecologist for nonurgent gynecologic issues. However, the academic family practice was well-equipped with a procedure room, electrocautery tools, and several physicians experienced with vulvar biopsy and primary care intrapartum obstetrics. After reviewing the risks of the procedure, including the life-threatening risk of vulvar hematoma, infection, incomplete removal, and recurrence, the patient provided informed consent for excisional biopsy of the lesion, which was determined to be a giant acrochordon.
The base of the mass was anesthetized with an injection of 1.5 mL of 1% lidocaine hydrochloride and epinephrine. The area was cleansed with chlorhexidine. The proximal aspect of the stalk was tied off with a size 2-0 nonabsorbable monofilament suture, with blanching of the mass ensuring an effective tourniquet-type reaction (Figure 2). A second size 2-0 nonabsorbable monofilament suture was used to tie off the proximal aspect of the mass, and again more blanching of the mass was demonstrated (Figure 3). Electrocautery, Monsel solution, and silver nitrate were all available for immediate hemostasis if needed; although a single cautery agent (either chemical or electrical) would have been sufficient it was not needed in this case. The mass was removed from the vulva by dissection using a scalpel between the 2 hemostatic ties. There was no visible bleeding of the vulva after removal of the mass. Two hemostatic interrupted sutures, with size 3-0 absorbable sutures, were used to provide additional hemostasis in case the hemostatic tie were to fall off the remaining stalk before healing could occur (Figure 4). The patient was counselled about red flags, including vulvar swelling and bleeding from the excision site, and was encouraged to present to the emergency department if these symptoms emerged. The mass was sent for pathologic examination.
Proximal tie after excision
Vulvar mass with distal tie
Absorbable suture placement
The patient returned to the office 6 weeks after the procedure. She had experienced no complications and there were no sutures visible. Inspection of the biopsy site revealed no mass or scar (Figure 5). The patient was happy with the cosmetic outcome.
Vulva 6 weeks after the procedure
Investigation
Histopathologic examination of the lesion revealed a benign mucosal skin tag with negative results for squamous intraepithelial lesion and malignancy.
Differential diagnosis
The differential diagnosis is broad and includes an acrochordon, hernia, neurofibroma, vulvar sarcoma, lipoma, Bartholin gland cyst, and vulvar varicosities.10 There is a rare report of a pedunculated vulvar mass diagnosed as basal cell carcinoma.11
Discussion
Case reports involving vulvar acrochorda are rare. A PubMed search involving the key words vulva, skin tag, and acrochorda revealed 6 case reports describing 7 vulvar acrochorda in patients ranging in age from 19 to 55 years old.2-8 The cases presented in a variety of settings: emergency departments, dermatology offices, and gynecology offices. The masses ranged in size from 9 cm to 20 cm. Acrochorda at other sites of the body typically range in size from 2 mm to 5 mm.4 Many of these case reports described removal or excisional biopsy while the patient was under general anesthesia in an operating room environment. Given the risks of general anesthesia and the scarce resource of operating room time, especially in a public health care system following the COVID-19 pandemic, this case demonstrates the importance of timely biopsy under local anesthesia in an office environment. Further, the literature around vulvar neoplasms indicates that patients often delay seeking attention for vulvar masses or vulvar skin changes for up to 16 months, and biopsy or referral to specialist care might be delayed by up to 12 months by primary care physicians.12 In this case, the patient did not seek care for the mass; instead, it was found on inspection of the vulva during a routine Pap test. If the patient had not presented for routine testing, then there might have been delays in identification and treatment for a non-benign lesion. Vulvar biopsy under local anesthesia is recommended; however, for large lesions, referral to a surgeon may be required.8,13
Conclusion
Family physicians play an important role in recognizing common vulvar dermatoses, and can expedite diagnosis and treatment and prevent unnecessary specialist referral by using common in-office surgical skills.
Notes
Editor’s key points
▸ Skin tags, also known as acrochorda, are common dermatologic conditions seen in primary care, but case reports involving vulvar acrochorda are rare.
▸ Literature about vulvar neoplasms indicates that patients often delay seeking attention for vulvar masses or vulvar skin changes. Biopsy or referral to specialist care might be further delayed by primary care physicians.
▸ Family physicians play an important role in recognizing common vulvar dermatoses, and can expedite diagnosis and treatment and prevent unnecessary specialist referral by using common in-office surgical skills.
Points de repère du rédacteur
▸ Les acrochordons sont des affections dermatologiques courantes en soins primaires, mais les études de cas portant sur les acrochordons vulvaires sont rares.
▸ La littérature sur les néoplasmes vulvaires indique que les patientes tardent souvent à consulter pour des masses vulvaires ou des modifications cutanées au niveau de la vulve. La biopsie ou le renvoi à un spécialiste pourraient être retardés davantage par les médecins de première ligne.
▸ Les médecins de famille jouent un rôle important dans la détection des dermatoses vulvaires courantes; ils sont en mesure d’accélérer le diagnostic et le traitement et d’empêcher le renvoi inutile à un spécialiste en recourant à des compétences chirurgicales usuelles en cabinet.
Footnotes
Competing interests
None declared
This article has been peer reviewed.
Cet article a fait l’objet d’une révision par des pairs.
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